Table of Contents

Introduction ................................................................................................................................................... 1

Oklahoma Office of Rural Health Partnership .......................................................................................... 2

Previous Community Health Needs Assessment- Priorities, Implementation, and Evaluation .................... 2

Pushmataha Hospital Medical Services Area Demographics ....................................................................... 5

Table 1. Population of Pushmataha Hospital Medical Service Area ................................................... 6

Table 2. Existing Medical Services in the Pushmataha Medical Services Area ................................... 7

Table 3. Percent of Total Population by Age Group for the Pushmataha Hospital and Home Health Medical Service Areas, Pushmataha County and Oklahoma ................................................................ 8

Table 4. Percent of Total Population by Race and Ethnicity for Pushmataha Hospital and Home Health Medical Service Areas, Pushmataha County and Oklahoma .................................................... 9

Summary of Community Meetings ............................................................................................................. 10

Economic Impact and Community Health Needs Assessment Overview, February 9, 2016 ................. 10

Table 5. Pushmataha Hospital Medical Service Area Health Sector Impact on Employment and Income, and Retail Sales and Sales Tax ............................................................................................. 12

Health Data, February 16, 2016 .............................................................................................................. 13

Table 6. Health Factors (Overall Rank 76) ........................................................................................ 14

Table 7. Health Outcomes (Overall Rank 72) .................................................................................... 15

Community Survey Methodology and Results, February 9- March 8, 2016 .......................................... 16

Table 8. Zip Code of Residence ......................................................................................................... 17

Table 9. Type of Specialist Visits ....................................................................................................... 18

Figure 2. Summary of Hospital Usage and Satisfaction Rates ........................................................... 19

Table 10. Top Healthcare Concerns in the Antlers Area ................................................................... 20

Table 11. Additional Services Survey Respondents Would Like to See Offered at Pushmataha Hospital ............................................................................................................................................... 21

Primary Care Physician Demand Analysis, March 8, 2016 .................................................................... 21

Table 12. Primary Care Physician Office Visits Given Usage by Local Residents in the Antlers, Oklahoma Medical Service Area ........................................................................................................ 22

Community Health Needs Implementation Strategy .................................................................................. 22

Community Health Needs Assessment Marketing Plan ............................................................................. 24

Appendix A- Hospital Services/Community Benefits ................................................................................ 25

Appendix B Community Meeting Attendees .............................................................................................. 26

Appendix C- Meeting 1 Materials, February 9, 2016 ................................................................................ 28

Appendix D- Meeting 2 Materials, February 16, 2016 .............................................................................. 31

Appendix E- Survey Form and Meeting 3 Materials, March 8, 2016 ........................................................ 34

1

Introduction

New requirements for nonprofit, 501 (c)(3), hospitals were enacted under the Patient Protection and Affordable Care Act (ACA), passed on March 23, 2010. One of the most significant of the new requirements is the Community Health Needs Assessment (CHNA) that must be conducted during taxable years after March 23, 2012 and submitted with IRS form 990. A CHNA must then be completed every three years following.

While the requirements are fairly new, the IRS has made strides in defining hospitals that must complete the CHNA as well as details of what is expected in the CHNA report to be submitted. At this time the only entities that must complete the CHNA are hospital organizations defined as:

An organization that operates a State-licensed hospital facility Any other organization that the Secretary determines has the provision of hospital care as

its principal function or purpose constituting the basis for its exemption under section 501 (c)(3).

The general goal behind the requirement is to gather community input that leads to recommendations on how the local hospital can better meet and serve residents’ needs. The community input is typically derived from a community survey and a series of open meetings. Local health data are presented. Community members then identify and prioritize their top health needs.

After listening to community input, the hospital defines an implementation strategy for their specific facility. The implementation strategy is a written plan that addresses each of the health needs identified in the community meetings. To meet Treasury and IRS guidelines an implementation strategy must:

Describe how the hospital facility plans to meet the health need, or Identify the health need as one the hospital facility does not intend to meet and

explain why the hospital facility does not intend to meet the health need1

After the needs are identified that the hospital can address, the implementation strategy must take into account specific programs, resources, and priorities for that particular facility. This can include existing programs, new programs, or intended collaboration with governmental, nonprofit, or other health care entities within the community.2

1 Internal Revenue Service. 2011. Notice and Requests for Comments Regarding the Community Health Needs Assessment Requirements for Tax-Exempt Hospitals. Internal Revenue Bulletin: 2011-30. 2 Ibid

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The facility must make the recommendations and implementation strategy widely available to community members. The facility must adopt the implementation strategy in that same taxable year.

Oklahoma Office of Rural Health Partnership

The Oklahoma Office of Rural Health makes this program available to all rural facilities in Oklahoma free of charge. The Oklahoma Office of Rural Health works closely with the hospital and community members to develop an economic impact of the local health sector, develop and analyze a local health services survey, and gather and analyze local health data. The community meetings are facilitated by a resource team that includes Corie Kasier and Lara Brooks of the Oklahoma Office of Rural Health.

After the meetings conclude, the resource team assists the hospital in developing their implementation strategy. After implementation, the resource team will assist in evaluation of the strategies implemented and provide continued assistance with data and resources.

This document discusses the steps taken to conduct a CHNA for Pushmataha Hospital in 2016. It begins with a description of the hospital’s medical service area, including a demographic analysis, and then summarizes each meeting that took place during the CHNA process. The report concludes by listing the recommendations that came out of the process and presenting the hospital’s implementation strategy and marketing plan.

Previous Community Health Needs Assessment- Priorities, Implementation,

and Evaluation

Pushmataha Hospital worked with the Oklahoma Office and Oklahoma Cooperative Extension Service in 2013 to complete their first Community Health Needs Assessment. During that time, health concerns were identified by community members and then prioritized by community members in focus group-style meetings. The following identifies each priority, implementation taken, and an evaluation or impact of the implementation.

Priority: Availability of doctors/Attracting new doctors

Service Implemented/Partnerships: Expanded specialist services

Cardiology and urology services have been added on a visiting basis for patients in Antlers and the surrounding area. Also, a general surgeon has a clinic in Antlers once per week and completes surgeries at Pushmataha Hospital (gallbladder, hernias, etc.) To date, 150 patients have benefited from local cardiology services, and nearly 160 patients have benefited from the availability of a urologist visiting Antlers on a monthly basis. There have been 350-500 general

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surgeries completed over the past year, which results in patients not having to leave the community or worry about transportation to these services.

Priority: Losing the hospital/Hospital closing

Service Implemented/Partnerships: Expanded service lines

During the 2013 CHNA, community members expressed concern of losing the hospital and associated services in the community. In response, the hospital has added and expanded service lines. MRI services have been added at the hospital, so patients do not have to travel (how many have benefited?). Swingbed program has been added (how many have benefited?), and outpatient physical therapy. The hospital added MRI services 3 years ago, and to date, there have been nearly 1,800 studies completed. Therefore, there are 1,800 instances where community members did not have to leave to the community to receive care. Nearly 1,000 patients have benefited from outpatient physical therapy since 2014, and nearly 100 patients have benefited from swingbed services.

Priority: Uninsured populations

Service Implemented/Partnerships: Case manager at hospital

The hospital has added a case manager to help provide information to patients about Medicare, Medicaid, and the health marketplace for individual insurance policies. The case manager impacts 1-2% of the patients that come to Pushmataha Hospital without insurance. This position also helps patients understand their discharge information and answers any questions that patients might have.

Priority: Uninsured populations

Service Implemented/Partnerships: Health Fair

The hospital hosts a health fair once per year, and approximately 30 participants attend on an annual basis. This is open to community members to receive valuable health-related information.

Pushmataha Hospital is an active participant in the local Turning Point coalition and supports local health related efforts such as the community baby shower, annual homecoming events and parade, and the local Deer Festival.

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Awareness of Community Outreach

A question was included on the community survey (complete methodology detailed on page 16) to gauge survey respondents’ awareness of current community programs offered by the hospital. Seven individuals or 20.0 percent of the total indicated they were aware of community programs. Survey respondents were then asked to list which programs they knew. Hospital auxiliary and the swingbed program were the only responses with one response each.

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Pushmataha Hospital Medical Services Area Demographics

Figure 1 displays the Pushmataha Hospital medical services area. Pushmataha Hospital and all area hospitals are delineated in the figure. The surrounding hospitals are identified in the table below by county along with their respective bed count.

Figure 1. Pushmataha Hospital Medical Service Areas

City County Hospital No. of Beds

Atoka Atoka Atoka County Medical Center 25 Durant Bryan Medical Center of Southeastern Oklahoma 148 Hugo Choctaw Choctaw Memorial Hospital 34 Coalgate Coal Coal County General Hospital 20 Wilburton Latimer Latimer County General Hospital 33 Idabel McCurtain McCurtain Memorial Hospital 91 McAlester Pittsburg McAlester Regional Health Center 171 Antlers Pushmataha Pushmataha Hospital and Home Health 23

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As delineated in Figure 1, the primary medical service area of Pushmataha Hospital includes the zip code areas of Antlers, Finley, Moyers, Snow, Rattan, and Nashoba. The primary medical service area experienced a population increase of 2.0 percent from the 2000 Census to the 2010 Census (Table 1). This same service area experienced a population decrease of 3.1 percent from the 2010 Census to the latest available, 2010-2014, American Community Survey.

The secondary medical services area is comprised of the zip code Clayton, Daisy, Atoka, Lane, Soper, and Spencerville. The secondary medical service area experienced an increase in population of 7.4 percent from 2000 to 2010 followed by a population decrease of 4.3 percent from 2010 to the 2010-2014 American Community Survey.

Table 1. Population of Pushmataha Hospital Medical Service Area

2000 2010 2010-2014 % Change % Change Population by Zip Code Population Population Population 2000-2010 2010-10-14

Primary Medical Service

Area

74523 Antlers 6,061 6,048 5,892 -0.2% -2.6%

74543 Finley 343 370 476 7.9% 28.6% 74557 Moyers 479 464 479 -3.1% 3.2% 74567 Snow 223 242 114 8.5% -52.9% 74562 Rattan 764 937 809 22.6% -13.7% 74558 Nashoba 477 455 481 -4.6% 5.7%

Total 8,347 8,516 8,251 2.0% -3.1%

Secondary Medical Service Area

74536 Clayton 1,632 1,760 1,765 7.8% 0.3%

74540 Daisy 209 172 164 -17.7% -4.7% 74525 Atoka 9,128 10,112 9,864 10.8% -2.5% 74555 Lane 996 861 663 -13.6% -23.0% 74759 Soper 1,281 1,358 1,236 6.0% -9.0% 74760 Spencerville 304 295 243 -3.0% -17.6%

Total 13,550 14,558 13,935 7.4% -4.3%

SOURCE: Population data from the U.S. Bureau of Census, Decennial Census 2000, 2010 and American Community Survey 2010-2014(January 2016)

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Table 2 displays the current existing medical services in the primary service area of the Pushmataha Hospital’s medical services area. The following medical services are available within the medical service area: one hospital, four physician offices and clinics, two dental offices, two nursing care facilities, two home health providers, Pushmataha County Health Department, one EMS provider, one rehabilitation provider, two counseling and mental health providers, and two pharmacies. Pushmataha is a 23 bed hospital located in Pushmataha County. The hospital provides acute and swing bed inpatient services, 24-hour services such as emergency department, laboratory, and radiology. Pushmataha Hospital also provides general surgery, blood banking, health screenings and health fairs. A complete list of hospital services and community involvement activities can be found in Appendix A.

Table 2. Existing Medical Services in the Pushmataha Medical Services Area

Count Service

1 Hospital: Pushmataha Hospital 4 Physician offices and clinics 2 Dental offices 2 Nursing care facilities 2 Home health providers 1 County Health Department: Pushmataha

County 1 EMS provider 1 Rehabilitation provider 2 Counseling and/or mental health providers 2 Pharmacies

In addition to examining the total population trends of the medical service areas, it is important to understand the demographics of those populations. Table 3 displays trends in age groups for the primary and secondary medical service areas as well as Pushmataha County in comparison to the state of Oklahoma. Overall, the over 65 age group has experienced an increase in population across all geographies from the 2010 Census to the latest, 2010-2014 American Community Survey. This cohort accounted for 14.0 percent of the total population at the state level. In terms of the medical service areas, this age group accounted for 21.6 percent of the primary medical service area, 18.0 percent of the secondary medical service area, and 21.1 percent of the population of Pushmataha County. The 45-64 age group accounts for the largest share of the population in the primary (27.7%) and secondary (27.0%) service areas and Pushmataha County (28.6%). This is compared to the state share of 25.4 percent of the total population.

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Table 3. Percent of Total Population by Age Group for the Pushmataha Hospital Medical

Service Areas, Pushmataha County and Oklahoma

Primary Medical Service Area

Secondary Medical Service Area

Pushmataha County Oklahoma Age

Groups 2010 Census

0-14 18.8% 19.7% 18.5% 20.7% 15-19 6.7% 6.8% 6.6% 7.1% 20-24 4.6% 5.7% 4.8% 7.2% 25-44 21.5% 24.8% 21.0% 25.8% 45-64 28.1% 26.9% 28.9% 25.7% 65+ 20.2% 16.2% 20.2% 13.5% Totals 100.0% 100.0% 100.0% 100.0%

Total Population 8,502 14,558 11,572 3,751,351

10-14 ACS

0-14 19.1% 18.8% 18.3% 20.6% 15-19 5.7% 6.1% 6.0% 6.8% 20-24 4.7% 6.4% 5.2% 7.4% 25-44 21.1% 23.7% 20.9% 25.8% 45-64 27.7% 27.0% 28.6% 25.4% 65+ 21.6% 18.0% 21.1% 14.0% Totals 100.0% 100.0% 100.0% 100.0%

Total Population 8,251 13,935 11,315

3,818,851 SOURCE: U.S. Census Bureau, Decennial Census data for 2010 and American Community Survey data for 2010-2014 (www.census.gov [January 2016]).

Changes in racial and ethnic groups can impact the delivery of healthcare services, largely due to language barriers and dramatically different prevalence rates for specific diseases, such as diabetes. A noticeable trend in Oklahoma is the growth in the Hispanic origin population. In 2010, those of Hispanic origin accounted for 8.9 percent of the total state population. The latest American Community Survey data of 2010-2014 suggest that this population group has experienced an increase to 9.4 percent of the total population. This trend is

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not as evident in Pushmataha County and both medical service areas. However, both medical service areas and Pushmataha County have a larger Native American share of the population when compared to the state. This cohort accounts for 10.9 percent of the primary medical service area population, 13.0 percent of the secondary, and 12.9 percent of the county population. This is compared to 7.2 percent at the state level.

Table 4. Percent of Total Population by Race and Ethnicity for Pushmataha Hospital

Medical Service Areas, Pushmataha County and Oklahoma

Primary Medical

Service Area Secondary Medical

Service Area Pushmataha

County Oklahoma Race/Ethnic Groups 2010 Census White 77.4% 71.8% 75.0% 72.2% Black 0.5% 4.0% 0.7% 7.4% Native American 1 15.7% 15.4% 17.6% 8.6% Other 2 1.2% 1.5% 1.1% 5.9% Two or more Races 3 5.2% 7.3% 5.7% 5.9% Hispanic Origin 4 2.7% 2.8% 2.4% 8.9% Total Population 8,502 14,558 11,572 3,751,351

10-14 ACS White 77.9% 72.1% 75.3% 73.3% Black 1.1% 3.9% 1.1% 7.3% Native American 1 10.9% 13.0% 12.9% 7.2% Other 2 1.4% 1.4% 1.3% 4.5% Two or more Races 3 8.8% 9.6% 9.3% 7.8% Hispanic Origin 4 3.0% 3.4% 3.0% 9.4% Total Population 8,251 13,935 11,315 3,818,851 SOURCE: U.S. Census Bureau, Decennial Census data for 2010 and American Community Survey data for 2010-2014 (www.census.gov [January 2016]). 1 Native American includes American Indians and Alaska Natives. 2 Other is defined as Asian Americans, Native Hawaiians, Pacific Islanders and all others. 3 Two or more races indicate a person is included in more than one race group. 4 Hispanic population is not a race group but rather a description of ethnic origin; Hispanics are included in the five race groups.

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Summary of Community Meetings

Pushmataha Hospital hosted three community meetings between February 9, 2016 and March 9, 2016. The Oklahoma Office of Rural Health facilitated these meetings. Summaries of the information presented at each meeting are included below in chronological order.

Community members in attendance at these meetings included:

Pushmataha Hospital representatives Pushmataha County Health Department Local mental health provider Rural health network representative

Average attendance at the community meetings was 3-10 community members. The community meetings were open for all community members to attend. Public leaders were invited to attend because of their impact on the growth of Pushmataha County. The hospital made significant efforts to reach a diverse and representative population of the medical service area and patients served including low income and racially diverse populations. Therefore, the local Department of Human Services office, Pushmataha Health Department, the local rural health clinic, and behavioral counseling services were all included. Representatives from the public health sector attended the community meetings to provide insight into what they see from a public health and underserved population perspective of community needs.

Economic Impact and Community Health Needs Assessment Overview, February 9, 2016

A meeting was held to discuss the economic impact of the health sector and explain the process and need for the Community Health Needs Assessment. The economic impact of the health sector was reviewed at this meeting (and is summarized below).

Table 5 below summarizes the overall economic impact of the health sector on the Pushmataha County, Oklahoma economy. A form requesting information was sent to all health care providers in the medical service area. Local providers were asked to share their employment levels and of those employees how many were physicians/optometrists/dentists/pharmacists/etc. When available, payroll information was also collected from the establishments. When payroll information was not available, payroll was estimated using state level averages from the Bureau of Labor Statistics.

The health sector in the Pushmataha medical service area employs 384 FTE individuals. After applying a county-specific employment multiplier to each respective sector, there is a total employment impact of 487 FTE employees. The same methodology is applied to income. The local health sector has a direct income impact of nearly $19.3 million. When the appropriate income multiplier is applied, the total income impact is over $22.8 million. The last two columns examine the impact this has on the retail sector of the local community. Recent data suggest that just 18.2% of personal income in Pushmataha County will be spent on taxable goods

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and services locally. Therefore, if we just examine the impact made on retail from those employed in the health sector, this would account for over $4.1 million spent locally, generating $41,572 on a 1% tax. A copy of the meeting materials that were distributed can be found in Appendix C.

At the conclusion of the meeting, community members were asked to identify their top health concerns based on the demographic information presented and their local expertise. The following concerns were identified:

• Access and availability of physicians • Recruitment/Retention of new providers (aging workforce) • Lack of education in the community

- Health literacy of local population - Patient compliance

• County-wide baby shower • Where do residents take their babies when sick?

• Access and availability of specialists - A cardiologist does come from Oklahoma City to see patients in Antlers

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Table 5. Pushmataha Hospital Medical Service Area Health Sector Impact on Employment and Income, and Retail Sales and Sales Tax

Employment Income Retail 1 Cent

Health Sectors Employed Multiplier Impact Income Multiplier Impact Sales Sales Tax

Hospitals 89 1.24 111 $3,084,395 1.18 $3,642,134 $662,868 $6,629

Physicians, Dentists, & Other Medical Professionals 96 1.34 129 $6,286,918 1.20 $7,531,722 $1,370,773 $13,708

Nursing Homes & Home Health 112 1.16 130 $5,319,445 1.16 $6,150,650 $1,119,418 $11,194

Other Medical & Health Services 67 1.40 93 $3,568,788 1.18 $4,193,511 $763,219 $7,632

Pharmacies 20 1.21 24 $1,074,876 1.23 $1,323,850 $240,941 $2,409

Total 384

487 $19,334,422

$22,841,868 $4,157,220 $41,572

SOURCE: 2014 IMPLAN database, IMPLAN Group, Inc.; Local data for employment, employee compensation and proprietor's income; income estimated based on state average incomes if local data not available

* Based on the ratio between Pushmataha County retail sales and income (18.2%) – from 2014 County Sales Tax Data and 2014 Personal Income Estimates from the Bureau of Economic Analysis.

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Health Data, February 16, 2016

A community meeting was held February 16, 2016, to examine various sources of local health data. Various sources of health data were examined including data from the County Health Rankings and Roadmaps Program through the University of Wisconsin Population Health Institute, and the Robert Woods Johnson Foundation and the 2014 Oklahoma State of the State’s Health Report compiled by the Oklahoma State Department of Health. The County Health Rankings program evaluates and ranks counties based on two distinct areas: Health Factors and Health Outcomes. Along with these two areas counties receive an overall rank within their state; therefore 1=best and 77=worst.

Health factors, considered tomorrow’s health, are comprised of health behaviors (rank: 76), clinical care (rank: 66), social and economic factors (rank: 75), and physical environment (rank: 37). Pushmataha County’s overall health factors rank is 76. Areas of concern include Pushmataha County’s smoking rate, adult obesity rate, food environment index, and teen birth rate are all less desirable than the top U.S. performers. Also, the uninsured rate, the county population per dental providers, and preventable hosptial stays, diabetic and mammography screenings of the Medicare population are all areas of concern in Pushmataha County. The high school graduation rate, share of children in poverty, share of children in single-parent households, injury deaths, and drinking water violations are also areas of concerns. All health factors variables are presented in Table 6 along with Pushmataha County specific data, the top U.S. performers, and the state average. The bold italicized categories are the areas identified by the County Health Rankings and Roadmaps as areas to explore (generally where Pushmataha County ranks very poorly compared to the national benchmark).

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Table 6. Health Factors (Overall Rank 76)

Category (Rank) Pushmataha

County

Error

Margin

Top U.S.

Performers Oklahoma

Health Behaviors (76) Adult Smoking 39% 30-48% 14% 24%

Adult Obesity 32% 26-38% 25% 32%

Food Environment Index 5.8 8.4 6.7

Physical Inactivity 32% 26-39% 20% 30%

Access to Exercise Opportunities 53% 92% 72%

Excessive Drinking 10% 13%

Alcohol-Impaired Driving Deaths 37% 14% 33%

Sexually Transmitted Infections 366 138 442

Teen Birth Rate 71 61-81 20 54

Clinical Care (66) Uninsured 26% 23-28% 11% 21%

Primary Care Physicians 2,801:1 1,045:1 1,567:1

Dentists 5,617:1 1,377:1 1,805:1

Mental Health Providers 101:1 386:1 285:1

Preventable Hospital Stays 103 88-117 41 71

Diabetic Screening 68% 58-78% 90% 78%

Mammography Screening 45% 35-55% 71% 55%

Social & Economic Factors (75) High School Graduation 80% 78%

Some College 50% 43-56% 71% 58%

Unemployment 7.6% 4.0% 5.4%

Children in Poverty 39% 29-48% 13% 24%

Income Inequality 5.0 4.1-5.8 3.7 4.6

Children in Single-Parent

Household 48% 37-59% 20% 24%

Social Associations 12.5 22.0 11.8 Violent Crime Rate 236 59 468

Injury Deaths 115 89-147 50 86

Physical Environment (37) Air-Pollution- Particulate Matter 10.4 9.5 10.3

Drinking Water Violations 49% 0% 23%

Severe Housing Problems 12% 9-16% 9% 14%

Driving Alone to Work 76% 71-80% 71% 82%

Long Commute- Driving Alone 31% 26-36% 15% 25%

Source: County Health Rankings & Roadmaps; University of Wisconsin Population Health Institute; Robert Wood Johnson Foundation

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The following figure depicts each county’s rank by shade. Pushmataha County’s ranking is comparable to McCurtain, Choctaw, Latimer, and LeFlore Counties and is less favorable than Pittsburg and Atoka Counties.

In terms of health outcomes, considered, today’s health, Pushmataha County’s ranking is 72nd in the state. Health outcomes are comprised of two areas: length of life and quality of life. The variables for each of these sections are presented in Table 7.

Table 7. Health Outcomes (Overall Rank 72)

Category (Rank) Pushmataha

County

Error

Margin

Top U.S.

Performers Oklahoma

Length of Life (60)

Premature Death 11,503 9,150-13,856

5,200 9,121

Quality of Life (76) Poor or Fair Health 30% 23-38% 10% 19%

Poor Physical Health Days 6.7 5.1-8.3 2.5 4.3

Poor Mental Health Days 5.1 3.2-7.0 2.3 4.2

Low Birth Weight 8.6% 6.9-10.4% 5.9% 8.3%

Source: County Health Rankings & Roadmaps; University of Wisconsin Population Health Institute; Robert Wood Johnson Foundation

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The following figure shows county health outcomes rankings by shades. Pushmataha County’s ranking is again comparable to Choctaw and McCurtain Counties and is less favorable than LeFlore, Latimer, Pittsburg, and Atoka Counties. All meeting materials distributed at this meeting can be found in Appendix D.

At the conclusion of the meeting, community members were once asked to identify what health concerns stand out in the data the presented and their local expertise. The health concerns identified include:

Access and availability of specialists - Cardiologist does come from Oklahoma City to see patients in Antlers - Urologist does see patients in Antlers - Working on getting orthopedics - General surgery is available with a clinic once per week and surgeries are

completed at Pushmataha Hospital Teen pregnancy is currently being addressed through the county health

department via a teen pregnancy nurse There are mental health providers available in county and now with telemedicine

medication management, more patients can benefit from these services

Community Survey Methodology and Results, February 9- March 8, 2016

A survey was designed to gauge hospital usage, satisfaction, and community health needs. The survey was available in both paper and web format. The survey link and hard copy surveys were shared with all Pushmataha Hospital employees who were encouraged to share the survey with friends, family and neighbors. The survey was also made available at outpatient

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registration at the hospital, local physician offices, and at the local post office. Surveys were also distributed at the first community meeting on February 9, 2016. Community members in attendance also received a follow-up email with a PDF copy of the survey and the electronic survey link. A copy of the survey form and results can be found in Appendix E. Community members were asked to return their completed surveys to Pushmataha Hospital.

The survey ran from February 9, 2016 to February 23, 2016. A total of 35 surveys from the Pushmataha Hospital medical service area were completed. Of the surveys returned, 3 were electronic responses. The survey results were presented at the March 8, 2016, community meeting.

Table 8 below shows the survey respondent representation by zip code. The largest share of respondents was from the Antlers (74523) zip code with 14 responses or 40 percent of the total. Atoka (74525) followed with 7 responses. Lane (74555) had 3 responses.

Table 8. Zip Code of Residence

Response Category No. % 74523- Antlers

14 40.0%

74525- Atoka

7 20.0% 74555- Lane

3 8.6%

74743- Hugo

2 5.7% 74426- Checotah

2 5.7%

74536- Clayton

2 5.7% 74501- McAlester

1 2.9%

74562- Rattan

1 2.9% 74735- Fort Towson

1 2.9%

74745- Idabel

1 2.9% 74753- Platter

1 2.9%

Total 35 100.0%

The survey focused on several health topics of interest to the community. Highlights of the results include:

Primary Care Physician Visits

- 54.3% of respondents had used a primary care physician in the Antlers service area during the past 24 months

- 94.7% of those responded being satisfied

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- Only 8 respondents or 22.9% believe there are enough primary care physicians practicing in Antlers

- 80.0% of the respondents would consider seeing a midlevel provider for their healthcare needs

- 77.1% responded they were able to get an appointment, within 48 hours, with their primary care physician when they needed one

Specialist Visits

Summary highlights include:

- 34.3% of all respondents report some specialist visit in past 24 months - Most common specialty visited are displayed in Table 9 - No specialist visits occurred in Antlers

Table 9. Type of Specialist Visits

Type of Specialist No. Percent

Top 5 Responses

Cardiologist 2 13.3%

(0 visits in Antlers)

Orthopedist/Orthopedic Surg. 2 13.3%

(0 visits in Antlers)

Bariatric 1 6.7%

(0 visits in Antlers)

Allergist 1 6.7%

(0 visits in Antlers)

Dermatologist 1 6.7%

(0 visits in Antlers)

All others 8 53.3%

(0 visits in Antlers)

Total 15 100.0%

Some respondents answered more than once.

Hospital Usage and Satisfaction

Survey highlights include:

- 66.7% of survey respondents that have used hospital services in the past 24 months used services at Pushmataha Hospital

o Oklahoma Heart Hospital, Oklahoma City, Choctaw Memorial Hospital, Hugo, Atoka County Medical Center, Atoka, INTEGRIS Health, Oklahoma

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56.3%

85.8%

66.7%

95.5%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Hospital Usage

Hospital Satisfaction

Pushmataha Hospital Other OK Hospital Survey Averages

City, Choctaw Nation Healthcare Center, Talihina, Jack C. Montgomery VA Medical Center, Muskogee all had 1 response each (3.0%)

o The most common response for using a hospital other than Pushmataha Hospital was availability of specialty care (33.3%) followed by closer, more convenient location (26.7%)

o The usage rate of 66.7% was higher than the state average of 56.3% for usage of other rural Oklahoma hospitals surveyed

- 95.5% of survey respondents were satisfied with the services received at Pushmataha Hospital

o This is above the state average for other hospitals (85.8%) - Most common services used at Pushmataha Hospital:

o Emergency Room (30.0%) o Physician Services (22.0%) o Laboratory (22.0%)

Local Healthcare Concerns and Additional Services

Survey respondents were asked what concerns them most about healthcare in their community. The most common response was Lack of providers/Recruitment of providers (16.2%) followed by No concerns/Receive good care/Don’t know (8.1%) and Lack of equipment and supplies (8.1%). Table 10 displays all responses and the frequencies.

Figure 2. Summary of Hospital Usage and Satisfaction Rates

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Table 10. Top Healthcare Concerns in the Antlers Area

Response Category No. % Lack of providers/Recruitment of providers 6 16.2% No Concerns/ Receive good care/Don't Know 3 8.1% Lack of equipment and supplies

3 8.1%

Quality of care/Professional care

2 5.4% Local care is undervalued and residents bypass local services 2 5.4% Lack of specialists

2 5.4%

Not enough providers accept SoonerCare

1 2.7% Losing the hospital

1 2.7%

Not enough care in general

1 2.7% Adequate space for providers

1 2.7%

Staying up-to-date on current illnesses

1 2.7% Technology and techniques seem underdeveloped 1 2.7% Shrinking reimbursements

1 2.7%

Not enough staff at clinic

1 2.7% Patients with a payer source

1 2.7%

Regulations for Medicare patients

1 2.7% No response

9 24.3%

Total 37 100.0%

Survey respondents also had the opportunity to identify what additional services they would like to see offered at Pushmataha Hospital. The most common response was Specialists (25.6%) with orthopedist having 4 responses, specialists in general with 2 responses, surgeon had 1 response, neurologist had 1 response, and internal medicine with 1 response. The next most common response was specialty services including bariatric services, urology clinic, and cardiac clinic with one response each or 7.0 percent, collectively. Table 11 displays the full listing of responses.

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Table 11. Additional Services Survey Respondents Would Like to See Offered at

Pushmataha Hospital

Response Category No. % Specialists: Orthopedist (4); Specialists in general (2); Pediatrician (2); Surgeon (1); Neurologist (1); Internal Medicine (1) 11 25.6% Specialty services: Bariatric services (1); Urology clinic (1); Cardiac clinic (1) 3 7.0% No additional services/Satisfied with what is available/Don't know 2 4.7% More providers

1 2.3%

A chapel

1 2.3% Critical care services

1 2.3%

MRI

1 2.3% Dialysis

1 2.3%

More community outreach/Community education 1 2.3% Home health

1 2.3%

Wound care

1 2.3% Advice nurse

1 2.3%

Improved quality of care

1 2.3% No response

17 39.5%

Total 43 100.0%

Primary Care Physician Demand Analysis, March 8, 2016 A demand analysis of primary care physicians was completed for the zip codes that

comprise the Antlers primary and secondary medical services areas. This analysis examined average primary care physician visit rates by gender and by age groups. Once age- and gender-specific coefficients were applied, total primary care physician visit numbers were calculated by service area. Table 12 displays potential primary care physician rates by shares of service area. For example, if 90% of residents in the primary medical services area and 10% of residents in the secondary medical services area utilize services of primary care physicians in the Antlers medical services area, a total of 15,895 annual visits would occur. This would suggest that the Antlers medical services area would need 3.8 FTE primary care physicians to meet the needs of their existing population. Table 12 displays the estimated number of visits by share of medical services area.

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Table 12. Primary Care Physician Office Visits Given Usage by Local Residents in

the Antlers, Oklahoma Medical Service Area

Usage by Residents of Primary Service Area

70% 75% 80% 85% 90% 95% 100%

Usa

ge b

y Re

side

nts o

f Sec

onda

ry

Serv

ice

Are

a

5% 11,701 12,452 13,202 13,953 14,704 15,454 16,205 10% 12,892 13,643 14,394 15,144 15,895 16,646 17,396 15% 14,083 14,834 15,585 16,335 17,086 17,837 18,588 20% 15,275 16,025 16,776 17,527 18,277 19,028 19,779 25% 16,466 17,216 17,967 18,718 19,469 20,219 20,970 30% 17,657 18,408 19,158 19,909 20,660 21,410 22,161 35% 18,848 19,599 20,350 21,100 21,851 22,602 23,352 40% 20,039 20,790 21,541 22,291 23,042 23,793 24,544 45% 21,231 21,981 22,732 23,483 24,233 24,984 25,735 50% 22,422 23,173 23,923 24,674 25,425 26,175 26,926

If 90% primary medical service area and 10 to 15% secondary medical service area, then the usage would be: 15,895 to 17,086 total primary care physician office visits in the Antlers area for an

estimated 3.8 to 4.1 Total Primary Care Physicians.

(Based on 83.7 average weekly primary care physician visits with a 50 week year)

At the conclusion of the meeting, community members were once again asked what stood out to them from the survey results and physician demand analysis as health concerns. The following concerns were identified and further discussed as top health priorities:

Health literacy Accessing providers, care after hours, long wait to see providers Health and wellness focus in the community

Community Health Needs Implementation Strategy

During the March 8, 2016, meeting, hospital representatives and community members discussed how these concerns can be addressed. The following lists the concerns along with steps the hospital and community plan to take to remedy the situation.

Health literacy- Patients often have difficulty understanding their physician orders, prescriptions, navigating the healthcare system, in the more extreme cases, patients end up in the emergency room.

– There are current efforts in the community to help address this issue. The local library in Antlers does have a literacy grant. A free health clinic is available

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every Thursday at the Antlers First Baptist Church. Patients without health insurance are seen at this clinic offering. The local librarian also meets with patients at this clinic to help educate patients on their orders and answering questions.

– The hospital does have a case manager to help patients better understand their discharge instructions and answer any questions patients might have. This service is available for inpatients and outpatients. The case manager also provides information about insurance and provides application and necessary paperwork for Medicare and Medicaid, including the additional information those need to complete after their online application for health coverage. (The case manager is not a patient navigator).

– The hospital plans to continue the focus of the case manager to education the patients on resources that are available to them as they become readily available. The hospital is striving to encourage back to school programs for those wanting to further their education.

Accessing providers, care after hours, long wait to see providers- Community members voiced this concern in two of the three community meetings. It was also noted that when patients have a long wait at the physician’s office this places a strain on those individuals, and those individuals have to take off more time from work. It was noted that the only option for care outside of the hours of 9am- 5pm is the emergency room. A community member also noted that there is a lack of pediatric care in the community, and patients travel to McAlester for care. Further, it was noted there is only one dentist in the county. The Clayton clinic does have a dentist, but it is on a sliding fee scale.

– Overall, the community would like to see an increase in primary care service and an option for after-hours care.

– In terms of specialty care, the hospital does have a cardiologist that comes once per month to see patients in Antlers.

– At this time, the hospital does not plan to offer alternative sites other than utilizing the local physician office or the urgent care clinic in Hugo.

Health and wellness focus in the community- This item was mentioned as a main focus area of the local health coalition. Sub-areas include tobacco usage, obesity, and physical inactivity.

– Pushmataha County has a Healthy Living task force that is working towards the Certified Healthy Incentive grant. With these funds, they will hire a planner for a master trails plan to increase physical activity among community members. This committee is also looking to add more physical activity equipment at the park.

– The coalition sponsored a Glow run in October 2015 at no cost to participants with over 300 participants. Funds have been set aside to offer this event again in the fall of 2016 (possibly as a kick off to Deer Fest).

– The health department will be hosting a community baby shower. This is the second offering; the first was a huge success. The health department does have a

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focus on teen pregnancy, not just prevention, but a focus on infant mortality and safe sleep.

– The coalition will also have a dental van set up in the community three days in September. This service will benefit community members with no insurance.

– All nurses as the hospital provide smoking cessation with patients and cover the 5 As. The tobacco helpline toll-free phone number is also provided to patients who are looking to quit. The hospital also provides free blood pressure and blood sugar checks to community members for no charge. This service is available at the hospital every Wednesday.

– The hospital continues to work for health and wellness in the community. The hospital educates staff on changing steps for common diseases, so this information can be disseminated to their patients. Grants that are available to the hospital are being utilized with a continued focus of support of local farmers’ markets and how to shop for healthier foods.

Community Health Needs Assessment Marketing Plan

The hospital will make the Community Health Needs Assessment Summary and Implementation Strategy Plan available upon request at Pushmataha Hospital, and a copy will be available to be downloaded from the hospital’s website (http://www.pushhospital.com/). This document will also be available on the OSU Center for Rural Health blog site: (http://osururalhealth.blogspot.com/p/chna.html).

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Appendix A- Hospital Services/Community Benefits

Pushmataha Hospital Services and Community

Benefits

Hospital Services:

24-hour Inpatient services 24- hour Emergency Room 24-hour Laboratory 24- hour Radiology General surgery Blood banking Dietary counseling (classes for diabetics) Health Screenings Health fairs Outpatient physical therapy Swingbed program MRI Services

Community Benefits

Free blood pressure checks at the hospital Deer Festival- booth on diabetes education, heart healthy, and hospital services Backpack program Antler’s Annual Homecoming events and Parade (floats in parade) The hospital provides meeting space for events MRI Services

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Appendix B Community Meeting Attendees

Antlers Community Health Needs Assessment

Meeting 1: Process Overview and Economic Impact Presentation

9-Feb-16

First Name Last Name Title Organization

Janette Henry RN Case Manager Pushmataha Hospital

Kate Trent HR Coordinator Pushmataha Hospital

Lori Smith, RN Adolescent Health OSDH

Jesika Reese Wellness Coach Sequel Care of OK

Jackie Sanders LPN Sequel Care of OK

Jaquetta Trotter RN-Site Manager Pushmataha Hospital

Nick Rowland COO Pushmataha Hospital

Owetha Wilson IT Director Pushmataha Hospital

Josh Braziel RHN Tech Director Rural Health Network of OK

Antlers Community Health Needs Assessment

Meeting 2: Health Indicators and Outcomes Presentation

16-Feb-16

First Name Last Name Title Organization

Janette Henry RN Case Manager Pushmataha Hospital

Jaquetta Trotter RN-Site Manager Pushmataha Hospital

Josh Braziel RHN Tech Director Rural Health Network of OK

Malissa Rains Marketing Director Pushmataha Hospital

Linda Callaway Health Promotions Strategist Oklahoma Health Care Authority

Ed Brooks

Hospital Auxiliary

Joyce Brooks

Hospital Auxiliary

Antlers Community Health Needs Assessment

Meeting 2: Health Indicators and Outcomes Presentation

8-Mar-16

First Name Last Name Title Organization

Kate Trent HR Coordinator Pushmataha Hospital

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Melissa Humphrey Wellness Coordinator Pushmataha County Health Department

Malissa Rains Marketing Director Pushmataha Hospital

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Appendix C- Meeting 1 Materials, February 9, 2016

29

30

31

Appendix D- Meeting 2 Materials, February 16, 2016

32

33

34

Appendix E- Survey Form and Meeting 3 Materials, March 8, 2016

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36

37

38

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